With the 2012 election over, President Obama re-elected, and Democrats retaining control of the Senate, implementation of the health system reform law they worked together to pass in 2010 will continue. But Republicans maintained control of the House of Representatives and, as AADA President Daniel M. Siegel, MD, noted in a message to the membership following the election, “Although implementation of the Affordable Care Act (ACA) will continue, significant opportunities to influence its direction remain.” How will the AADA achieve that influence? And how will dermatology ensure that its key advocacy priorities, which relate to Medicare physician payment, the Independent Payment Advisory Board (IPAB), and indoor tanning, are advanced given the outcome of the election?

Physician payment

Immediately after the election, as they have almost every year for more than a decade, the AADA and the rest of the house of medicine faced the challenge of ensuring that cuts to Medicare payments required by the sustainable growth rate (SGR) formula, a relic of 1997’s Balanced Budget Act, did not come to pass. The Academy joined more than 100 other medical associations in proactively recommending a path forward toward a permanent fix, signing on to a letter to the chairs of the relevant House and Senate committees that offered suggestions for replacing the SGR designed to guide the discussion about new payment models while ensuring that physicians can continue to provide optimal care to patients. [pagebreak]

The letter acknowledged that “new payment models are needed that can offer physicians opportunities to lead changes in care delivery while being rewarded for improving the quality of patient care and lowering the rate of growth in costs,” noting that, as the system currently works, those “who lower total health care costs through delivery improvements are not rewarded and may actually lose revenue.”

“We’re working very hard, both as an Academy and with the rest of medicine, to make sure that dermatology is not left out of the loop and that the payment reforms and systems that have been proposed will make it possible for us continue to practice dermatology and be reimbursed fairly,” said Sabra Sullivan, MD, PhD, chair of the AADA’s Congressional Policy Committee.

Indeed, according to Marta VanBeek, MD, MPH, chair of the AADA’s Council on Government Affairs, Health Policy, and Practice, “The Academy has moved beyond just asking for a fix to the SGR to really trying to explore other innovative payment options. We now have a workgroup on innovative payment and delivery reform, which is looking at other payment options besides fee-for-service, and our advocacy efforts are looking more long term instead of just at short-term fixes to the SGR. Of course, we want that, but we also want a stable payment system and that is going to take quite a bit of work. The Academy is working hard on looking at Medicare claims data to figure out, what would alternative fair models of payment be instead of fee-for-service?” [pagebreak]

That hard work is being led by Kathryn Schwarzenberger, MD, a member of the Academy’s Board of Directors who chairs the Workgroup on Innovative Payment and Delivery. The Academy is in the process of developing data that will help individual dermatologists determine the potential impact of various proposed payment and delivery models, including patient-centered medical homes, accountable care organizations (ACOs), bundled episodes of care, and capitated payments, on their practices, she said. “The data, when it’s ready, should let people determine how their practice mix would be affected by each of the proposed models,” she said. “We want to provide information that will allow dermatologists who, for example, are approached about joining an ACO, to assess the impact of that proposal on their practices and how they can provide the best care for their patients in the changing market.”

That work may take some time. So the medical societies also stressed in their letter to Congress that new payment models “must be developed during a defined and robust transition period that can fill in the gap between elimination of the SGR formula and implementation of a new system nationwide,” as “physician practices of every size and specialty must be supported and encouraged to develop the needed infrastructure and begin adopting the most appropriate model for their patients and their practice.”

With the SGR cut ameliorated for another year as part of the overall fiscal cliff deal, the AADA will continue to work with the rest of medicine to push Congress to adopt a permanent solution. “People on both sides of the aisle agree that they don’t want the cuts to happen,” according to Shawn Friesen, the AADA’s director of legislative, political, and grassroots advocacy — that’s why the two sides eventually agree on payment freezes or slight increases each year. However, he added, “there’s a divergence of opinion on how to pay for and implement a permanent fix.” The intent expressed by both parties to achieve real solutions this year rather than once again kicking the can down the road could finally open the door to such a fix, though. [pagebreak]

“It’s possible that a larger SGR fix could be part of a grand-bargain-type deal if there is agreement to arrive at some kind of deal in 2013,” Friesen said. “It could happen as part of a big package. And there’s no election for almost two years — there’s a lot of potential for deal-making, depending on how the parties perceive their political capital and incentives.”

IPAB

According to Dr. Siegel in his post-election message, “The AADA is working to influence various changes to parts of the law that may mitigate the negative effects on our specialty and our patients.” One of the key areas of focus in this regard is IPAB, a board charged with controlling Medicare spending by making annual cost-saving recommendations that Congress must accept as a slate or amend to achieve the same savings. The model is similar to the commission used to determine which military bases can be shut down.

IPAB’s first recommendations are scheduled to be due to Congress on Jan. 15, 2014, with a public report due July 1, 2014. However, the trajectory of overall Medicare spending has been lower in the last few years than it was during the reform debate of 2009 and 2010, and CMS now projects that IPAB’s cost-saving recommendations will not be necessary until 2018. Nevertheless, the board’s potential power to make recommendations for cuts to spending that would not be subject to the normal legislative process makes it a significant concern for physicians. [pagebreak]

“As far as repeal of IPAB, we’re still thinking it through,” Dr. VanBeek said. “It is an uphill battle because the people who voted for IPAB are still in power. It wasn’t necessarily a bipartisan provision so there is some possibility of it getting repealed, but it’s unlikely. Repeal remains our number-one priority, but we are also trying to figure out how we can best function if that doesn’t happen,” she said. In his message to the membership, Dr. Siegel stressed the same thing: “While some members of Congress will continue to work to repeal IPAB, we are also working with our colleagues across the medical profession to prepare for the possibility of IPAB’s formation and to develop strategies to ensure that the perspective of physicians is represented should it move forward as envisioned in the ACA.”

The unchanged post-election environment creates an interesting situation for IPAB in the near future, Friesen said.

“At this point, repeal is unlikely,” he said, though he acknowledged that there are Democrats and Republicans who do not support the IPAB. “But whether there are tweaks that will happen that’s where it gets interesting. What does Senate confirmation mean? What if there aren’t 60 votes to fill an IPAB slot? Are recess appointments a possibility?” [pagebreak]

If the Obama administration chose to make such appointments, which allow the president to fill vacancies when the Senate is in recess, the composition of the IPAB would, hypothetically, allow it to convene and begin making recommendations without any Republican support. The IPAB’s 15 voting members are to include:

three members chosen by the president in consultation with the top-ranking Republican in the House,

three members chosen by the president in consultation with the top-ranking Democrat in the House,

three members chosen by the president in consultation with the top-ranking Republican in the Senate,

three members chosen by the president in consultation with the top-ranking Democrat in the Senate, and

three members chosen by the president on his own.

The nine members who could be appointed without consulting Republicans at all would give IPAB a quorum to operate. IPAB will also include, in non-voting capacities, the secretary of Health and Human Services (HHS), the administrator of the Centers for Medicare and Medicaid Services (CMS), and the administrator of the Health Resources and Services Administration (HRSA).

Republicans in Congress could still influence IPAB, though, according to Friesen. “How can they impact its funding? Congress does have the power of the purse; it’s possible they would try to find ways to cut IPAB’s funding and inhibit its operations.”

For more detail on how IPAB is designed to function and its potential impact on dermatology, read Dermatology World's March 2011 article on the topic. [pagebreak]

Indoor tanning

One bright spot for dermatologists dismayed by the prospect of continued implementation of reform is the possibility that the Academy’s work on indoor tanning will bear fruit under the current administration.

“Indoor tanning is still a priority at the state and federal level,” Dr. VanBeek said. “Our State Policy Committee is working very hard to support state societies that introduce bills to ban underage tanning. We’re also making progress on the FDA reclassification of tanning beds.” But in addition to working with the FDA, she said, “we’re also still supporting the Tanning Bed Act, which has been introduced several times before in Congress and would reclassify tanning beds and provide better warning labels that would be more obvious in appearance.” Dr. VanBeek said that momentum is on the side of those who see the danger of tanning, as more countries and international organizations label it a carcinogen. “We’ll keep getting broader support for tanning legislation as more data comes out and the rest of the world recognizes it for the carcinogen it is,” she said.

Work to make that happen is ongoing, according to Leslie Stein Lloyd, JD, the Academy’s director of regulatory and payment policy, and continuing to deal with the same administration increases the likelihood that progress to-date will continue. With regard to tanning beds, she said, the FDA still has to determine whether it will recommend reclassification of tanning equipment based on the hearing it held in 2010 and the evidence it has received since then. “We are hopeful that reclassification will happen. We’ve been advocating throughout the rulemaking process, encouraging the FDA to reclassify, and when new studies regarding the impact of indoor tanning on melanoma and other skin cancers have come to light, we have shared those studies to ensure that the FDA is kept abreast of the latest developments.” The rule that will determine whether tanning equipment is reclassified is moving through the usual regulatory process, she said, and without changes at the top of the Department of HHS or the FDA, an announcement by mid-2013 seems possible. [pagebreak]

Whether or not the FDA acts on tanning beds, Lloyd said, the Academy has other work planned to spread its message about indoor tanning. “We have contracted with the Research Triangle Institute to study the impact of indoor tanning on melanoma and the costs associated with indoor tanning. They’re in the process of doing an economic analysis on a state-by-state basis; we look forward to it being another tool to help persuade policymakers; we can use it both in the states and nationally, with legislators and with regulators.”

Beyond pushing for legislation and regulation, Lloyd said, “The next step for us is to work with the Surgeon General’s office to create a call for action to stop indoor tanning.” To that end, Dr. Schwarzenberger recently met with dermatologist Boris Lushniak, MD, MPH, the deputy surgeon general.

“We discussed our mutual concern about tanning as a significant public health issue,” Dr. Schwarzenberger said. “Clearly the Surgeon General’s office is aware of this issue and shares our zeal to do something about it. We were reassured that they understand the importance of promoting healthy behavior, including reducing the incidence of indoor tanning.”

The discussion also turned to the government’s Healthy People 2020 initiative and the role of dermatologists in the improvement of public health in the country in general. “We agreed that anything we can do to improve participation among dermatologists in the improvement of public health in the country in general would be valuable,” she said. Such efforts could include work with the Public Health Service, perhaps in the prison system, where treatment of prisoners using a teledermatology system could develop and prosper, or in the Medical Reserve Corps. Such activities would have the added benefit of increasing dermatology’s ties to the rest of medicine, she said, a critical element in helping the specialty define its role in the changing health care environment. [pagebreak]

Helping members with reform

As reform moves forward, the Academy has tasked itself with helping members figure out what it means for them as individuals and as a specialty.

“Because of the election results and the ACA, dermatologists have to think very hard about how we fit into the rest of medicine and what kind of critical component of medical care we provide our patients,” Dr. VanBeek said. “We will no longer be in isolated silos of specialty care. We have to think of a more integrated approach and be innovative in thinking about how we complete the full medical care of our patient,” she said, pointing to the efforts of the Workgroup on Innovative Payment and Delivery.

While that work continues, Friesen also noted that “now that we know that health reform will go forward, we’re going to be helping our members adapt to a changing environment.” As implementation of reform continues and new rules and requirements take effect, dermatologists can continue to look to the Academy for help understanding what the changes mean for them. But Dr. Schwarzenberger warns that there is no one-size-fits-all answer. [pagebreak]

“In an ideal world we’d be able to come out with clear information saying, health care reform is going to do X to you,” she said. “But what’s clear to all of us working on this is that the face of the market will be different in every community. How reform will impact your practice will be very personal depending on your practice environment. You’re less likely to have the care pattern dictated to you, for instance, if you are the only person in the community available to provide the care.” To help the Academy generate the most meaningful resources possible, she said, members should let the Academy know about their experiences with new payment models via email to share their story.

Currently available resources for coping with reform are already robust. The AAD website is adding resources designed to help members with implementation and includes a new ACO Resource Center. Dermatology World has produced a variety of resources related to both ACOs and to the broader impact of reform.

Moving forward

As they address reform’s impact in their practices, Academy members can keep up to date on the latest advocacy news related to reform via the Academy’s bi-weekly e-newsletter, Dermatology Advocate. Even since the election, Dr. Sullivan said, the Academy has been fighting for its members. [pagebreak]

“We’ve been supporting legislation to make sure that the EHR rules and regulations are administered fairly and people aren’t penalized without due process,” she said. The EHR Improvements Act, introduced in the House of Representatives in the last Congress, would create a hardship exemption from upcoming Medicare penalties related to EHR use for small practices and physicians approaching retirement and establish an appeals process before any penalties would be applied. Both provisions could benefit numerous dermatologists.

That example is one of many to come, Dr. Sullivan suggested.

“It’s going to be critically important for us to be there at every step as the law is interpreted to ensure that it doesn’t have a negative impact on our community,” she said. “We had contingency plans regardless of who won the election, and we’re trying to put forth strategies that ensure that our patients get the best care possible, protect and foster the specialty of dermatology, and help move our nation forward out of the chaos we’ve been in while protecting our ability to provide care. We’re trying to work within the system to move it forward.” [pagebreak]

The Academy can provide resources and advocate on members’ behalf, Dr. Schwarzenberger said, but individual dermatologists also need to get involved to understand and affect their unique circumstances.

“It’s important for dermatologists to be active in their medical communities so they can see the changes that are coming and be proactive and involved,” she said. “Stay in touch with your colleagues, go to your medical society meetings. We can’t ignore the infrastructures of medicine. Those days are over.”

The bottom line, Dr. Sullivan said, is that members cannot become complacent.

“We all have to be very involved in the process. The Academy will keep working. Even if the outcome isn’t what you hoped for, instead of gnashing your teeth, we have to sit down and figure out the best way to protect ourselves and our patients and then get going to do the best we can.”